The technique of Superior Capsular Reconstruction has been presented in a recent video (see this link).
In this case injection of a bone marrow aspirate was added to the procedure
The costs of the procedure have been estimated in a recent article: Superior Capsular Reconstruction for Massive Rotator Cuff Tears A Critical Analysis Review
Comment: What remains to be clarified is the indications for this procedure. In the video, the patient had this history
In such a patient with 5-/5 strength of supraspinatus and 160 degrees of forward flexion, one might consider a less costly and less complicated procedure, the smooth and move (see this link), which enables immediate postoperative resumption of active use of the arm, rather than the more restrictive rehabilitation program described above. In order to determine the value of the superior capsular reconstruction, a controlled trial comparing these two approaches for patients with irreparable cuff tear and retained active elevation is needed.
The published early and longer term outcomes from the smooth and move procedure are summarized below.
These authors point out that it has been previously documented that the smooth and move procedure—smoothing the proximal humeral surface while maintaining the coracoacromial arch—can provide clinically significant long-term improvement in function for patients having irreparable rotator cuff tears with retained active elevation (see previous blog post that is reproduced below).
In this study they sought to demonstrate that clinically significant gains in comfort, function, and active motion can be realized as early as 6 weeks after this procedure. They conducted a prospective cohort study of the 6-week clinical outcomes for 48 patients enrolled prior to a smooth and move procedure for irreparable rotator cuff tears. Prior rotator cuff repair had been attempted in 28 (70%).
In 40 patients with preoperative and 6-week postoperative measurements, the Simple Shoulder Test scores improved from an average of 3.4 ± 2.8 preoperatively to 5.7 ± 3.5 at 6 weeks (p < 0.001), an improvement that exceeded the published values for the minimal clinically important difference (MCID).
The clinical outcomes were not worse for the 18 shoulders with irreparable tears of both the supraspinatus and infraspinatus.
In 30 patients with preoperative and 6-week postoperative objective measurements of active motion, the average abduction improved from 93(± 43) to 123(± 47)° (p = 0.005) and the average flexion improved from 102(± 46) to 126(± 44)° (p = 0.023).
They concluded that in addition to its previously documented long-term effectiveness for shoulders with irreparable rotator cuff tears and retained active elevation, this study demonstrates that the smooth and move procedure provides clinically significant improvement as early as 6 weeks after surgery.
They concluded that in addition to its previously documented long-term effectiveness for shoulders with irreparable rotator cuff tears and retained active elevation, this study demonstrates that the smooth and move procedure provides clinically significant improvement as early as 6 weeks after surgery.
They present the case example of a 71 year old physician photographer with a failed prior cuff repair attempt. Here is the preoperative radiograph
At surgery he had no supraspinatus or infraspinatus. The debris shown below was removed from his humeroscapular motion interface
This video (used with permission of the patient) shows his function 6 weeks after surgery.
Eight weeks after surgery he was photographing north of the Arctic Circle. Here's one of his photos.
This study should be considered along with a prior study, which is discussed below.
Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty
These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation (>100 degrees) can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.
The typical pathology in these cases is shown in the figure below.
In 77 shoulders with previously unrepaired irreparable tears, Simple Shoulder Test (SST) scores improved from an average of 4.6 (range 0–12) to 8.5 (range 1–12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points.
The surgical approach is through a deltoid splitting incision that preserves the deltoid origin, the acromion and the coracoacromial ligament.
The coracoacromial arch is preserved to avoid the complication of anterosuperior escape that is commonly encountered when acromioplasty is performed in the presence of a large cuff tear.
The surgery includes smoothing of the prominence of the greater tuberosity that is exposed in cuff tears along with resection of adhesions in the humeroscapular motion interface and a gentle manipulation under anesthesia to resolve the stiffness that is commonly associated with chronic cuff tears. Immediate active assisted and active motion are encouraged immediately after surgery. Because no repair or reconstruction has been performed, activities, including deltoid strengthening can be resumed as soon as they are comfortable.
They reviewed 151 patients with a mean age of 63.4 (range 40–90) years at a mean of 7.3 (range 2–19) years after this surgery. The patient data are shown below, contrasting the patients that did and did not improve by the MCID of 2 in the Simple Shoulder Test
For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0–11) to 7.5 (range 0–12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.
They provided this case example. A rancher in his mid 60s had a right rotator cuff reconstruction with freeze-dried acellular human dermal collagen tissue matrix that subsequently became infected. He presented to us with a painful stiff right shoulder. At surgery there was extensive scar throughout the humeral scapular motion interface. The subscapularis was detached but was reconstructible. The supraspinatus was absent. The upper 2/3 of the infraspinatus was absent as well. The tuberosities were prominent. He had a smooth and move procedure at which time the abundant scar in the humeral scapular motion interface was debrided. The previous sutures and Graft Jacket were excised. The bursa was removed. The prominent tuberosities were resected using a rongeur and a burr. A manipulation under anesthesia was performed to assure a full passive range of motion. Passive and active range of motion exercises were started immediately after surgery. Three years later he reported excellent shoulder comfort and function and sent us this photo of his return to one of his favorite activities
They concluded that smoothing of the humeroscapular interface can durably improve symptomatic shoulders with irreparable cuff tears and retained active elevation > 100 degrees. They point out that this conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.
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Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
Use the "Search" box to the right to find other topics of interest to you.
How you can support progress in shoulder surgery
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